Lisa Heelan FNP Family Health Promotion 1 Commonly

Lisa Heelan, FNP Family Health Promotion 1 Commonly Occurring Infections

Learning Objectives Summarize modes of transmission, treatments and descriptions of the most commonly occurring sexually transmitted infections (STI’s) Summarize the health teaching that a nurse needs to provide to a woman with an STI Relate the implications of pelvic inflammatory disease (PID) for future fertility to its pathologic origin, signs and symptoms and treatment

Compare the different types of hepatitis Compare vulvovaginal candidiasis and bacterial vaginosis Discuss acquired immunodeficiency syndrome (AIDS), including care of the pregnant woman with HIV/AIDS, neonatal implications and ramifications for the childbearing family

Normal Vaginal Flora

Vulvovaginal Candidiasis (Yeast) Thick, white vaginal discharge Severe itching, dysuria and dyspareunia Treatment: Miconazole cream

Clinical Thinking in Action Maria is a 24 year old woman who is coming to the clinic for the 4 th time this year with complaints of vaginal itching and thick cottage cheesy discharge which started again yesterday. Maria denies any change in her sexual partner, but loves to run five miles per day. cells and a negative Wiff test Her wet mount shows a +KOH with no WBC’s, no clue.

If a woman experiences frequent recurrences of monilial vaginitis, what should she be tested for?

What about a pregnant woman who has a yeast infection? Can this be a serious condition for the newborn?

The client being given discharge instructions with a diagnosis of vulvovaginal candidiasis demonstrates understanding when she states, “I need to: 1. 2. 3. 4. Wear nylon panties Apply the miconazole (Monistat) for 10 days Consider taking acidophilus daily Douche daily

Bacterial Vaginosis Overgrowth of normal vaginal flora Thin, watery, whitegrey discharge “Fishy” odor Treatment: Flagyl

Increased risk of pelvic inflammatory disease (PID) Abnormal cervical cytology (pap) Increased risk for premature rupture of the membranes (PROM) Preterm labor Postcesarean endometritis

omoniasis Trich Transmission: Sexual intimacy Symptoms: asymptomatic or mild * yellow-green frothy, odorous discharge *Vulvar itching Treatment: Metronidazole

Critical Thinking in Action Ann is a 31 year old woman who now has a new sexual partner. She has been inconsistent with using condoms. She presents to the clinic with some vaginal itching and a bad odor that she says she has never had before. On exam, the wet mount shows: –wbc’s, -clue, +wiff and Trichomonas vaginalis. Her pregnancy test is +.

Ann understands why she can’t drink alcohol, because she is pregnant, but she can’t understand why her boyfriend can’t drink alcohol if he takes flagyl. What do you tell her?

What are pregnant women with trichomoniasis at increased risk for? Can they be treated with metronidazole (flagyl)?

Ann can’t understand that if she is treated, and her boyfriend has started treatment, why they have to abstain from sex. What do you tell her?

A nonpregnant woman reports a fishy smelling, thin, white watery vaginal discharge. She is diagnosed with BV. The client reports an allergy to sulfa. What will the nurse adminster? 1. 2. 3. 4. Metronidazole (flagyl) 500 mg po bid for a week Penicillin G (Bicillin) 2 million units IM x 1 Doxycycline (Vibramycin) 100 mg po bid for a week Zithromax (Azithromycin) 1 mg po bid for 2 weeks

Chlamydial Infection Most common STI in the United States Transmission: Vaginal, anal & oral Symptoms: 70% of women have no symptoms Treatment: Azithromycin or Doxycycline http: //www. cdc. gov/std/Chlamydia/STDFact-Chlamydia. htm

Gonorrhea…. Transmission: vaginal, anal, or oral sex Symptoms: 80% of women are asymptomatic Treatment: Ceftriaxone IM

Symptoms of chlamydia and/or gonorrhea…. Men Discharge from the penis Burning sensation while urinating Tender or swollen testicles Women Burning sensation while urinating Abnormal vaginal discharge Abdominal pain Unusual vaginal bleeding Men and Women Anal itching Soreness Bleeding Painful bowel movements Eye infections Blood infections

On a wet mount…. increased white blood cells

Critical Thinking in Action Cherelle, age 18, was just diagnosed with gonorrhea by the nurse practitioner at the clinic where you work. Although she had been asymptomatic, she had come in for evaluation after her boyfriend was diagnosed with gonorrhea and started on antibiotics. Cherelle is treated with ceftriaxone IM plus doxycycline bid x 1 week.

Cherelle asks you why she received two medications, when she only had gonorrhea? How would you reply?

Cherelle asks you whether she is now immune to gonorrhea. Is she?

Cherelle asks whether she can now have sex with her boyfriend. Can she do so?

While Cherelle is not pregnant, what might happen to her fetus if she was pregnant and had a chlamydial infection that was not treated?

Pelvic Inflammatory Disease What are the symptoms of PID? When should a woman be hospitalized? http: //www. cdc. gov/std/ PID/STDFact-PID. htm

Which of the following diagnostic tests would the nurse question when ordered for a client diagnosed with pelvic inflammatory disease (PID)? 1. 2. 3. 4. Throat culture for Strep tococcus A CBC (complete blood count) Culture for Neisseria gonorrhea RPR (rapid plasma reagin)

The nurse’s discharge teaching plan for the woman with PID should reinforce which of the following potentially life threatening complications? 1. 2. 3. 4. Involuntary infertility Chronic pelvic pain Depression Ectopic pregnancy

Herpes Genitalis � Primary severe episodes most � Vesicles may appear within a few hours up to 21 days after exposure � Flu-like HSV 1? , HSV 2? symptoms, genital tingling or pruritus � Lesions heal on own within 2 weeks

Herpes…. � Transmission: vaginal, anal or oral � Skin to skin contact � 50 million people in US have it � Treatment: acyclovir Oral

Can increase spontaneous abortion if primary infection occurs in first trimester Intrauterine growth restriction and neonatal infection in 2 nd or 3 rd trimester Risk to fetus varies and is dependent on route of birth and whether lesions present at delivery are recurrent or primary

Symptomatic newborns with Herpes Fever Jaundice Seizures Poor feeding ½ develop herpetic lesions Treated with acyclovir

Syphilis…. Bacterial Organism: Treponema pallidum Transmission: *Vaginal, oral or anal *Exposure to exudate from infected individual * Transplacental Symptoms: Early stage: Chancre, fever weight loss, malaise

Syphilis…. . Symptoms of second stage: *Condylomata lata on vulva, acute arthritis *Enlargement of liver and spleen, lymph nodes *Chronic sore throat

Critical Thinking in Action Mary is a 24 year old pregnant woman, 19 weeks gestation. She recently noticed a sore in the vulva area that didn’t hurt or itch, but it has been persisting for about 2 weeks now. Mary is concerned because the father of the baby had been in prison, and a friend of hers told her that men in prison have sex with other men. Now, Mary wants to be checked for everything, and isn’t sure she wants to remain in the current relationship.

Mary’s RPR titer turns out to be + for syphilis. She needs to be treated, and will be given Penicillin G. Mary asks about what effect this disease may have on her fetus. You reply?

Why is testing done at the initial prenatal screening, and repeated in the 3 rd trimester on all pregnant women?

HPV In the US, 20 million men & women are infected 2. 3% of women ages 14 -59 are infected with cancer causing strains HPV type 16 or 18

Genital Warts…. � Viral organism: HPV � Transmission: Vaginal, or anal sex � Symptoms: Painless Pruritus � Treatment: Client or provider therapies for wart removal

Women with HPV Should have paps or thin preps every 6 months depending on their age May need colposcopies Instructed in safer sex practices and screened for other STI’s

A woman with HPV is likely to present with which nursing assessment finding? 1. 2. 3. 4. Profuse, pus-filled vaginal discharge Clusters of genital warts Single painless ulcer Multiple vesicles on genitalia 10

Men with HPV Prevalent in both heterosexual and homosexual men q q HIV+ men had higher rates of anal cancer

Anal Cancer Affects 4, 600 men & women each year 700 people die

Approved by FDA in June 2006 3 injections over 6 months at a cost of $150/injection For use in males & females starting at age 9 to 26 Protects against HPV strains 16 & 18 that causes 70% of all cervical cancers and types 6 & 11 which causes 90% of genital warts

Gardasil Vaccine Doesn’t contain mercury, thermosol or live or dead virus, only virus like particles Questionable length of protection---may need to be revaccinated within 5 years of receiving initial vaccine Will continue to need annual paps Side effects—no long term studies

Cervarix Protects against HPV strains 16 & 18 FDA approved in October 2009 Manufactured by Glaxo. Smith. Kline Approved for use in females age 10 -25

To confirm a finding of primary syphilis, the nurse would observe which of the following on the external genitalia? 1. 2. 3. 4. A highly variable skin rash A yellow-green vaginal discharge A non tender, indurated ulcer A localized gumma formation

Vital Statistics: United States An estimated 1. 2 million people are living with HIV/AIDS, with approximately 40, 000 new infections each year 30% of these new infections are occurring in women 75% of these new infections are heterosexually transmitted

US Demographics (2006) US female population AIDS diagnoses among females 13 and older African American 12% White 68% Other 6% African American 66% Latina 14% White 17% Latina 16% Other 1% CDC, 2006

Geography 1/3 of those estimated to be living with AIDS in NJ, Maryland, Connecticut, Delaware and the Virgin Islands are female 7 of the 10 states with the highest case rates among women are in the South, with Washington, DC topping the list.

Profile of women at risk for HIV/AIDS 71% of the women with AIDS are diagnosed between the ages of 25 and 44 The AIDS case rate severely impacts women of color 2/3 of women with AIDS had an annual income below $10, 000

“The curse that afflicts African women, as well as our Black sisters in the United States, is fueled by something pretty straightforward: poverty. AIDS thrives in situations of high socio-economic vulnerability, a condition that influences behavior, disease and risk. ” Doras Chirwa HIV/AIDS coordinator for CARE Zambia

Poverty 37 million Americans live in poverty, which is 12. 7% of the US population 30% of all African American children live below the poverty line In 2006, the poverty rate for minors in the US was 21. 9%---the highest poverty rate in the developed world.

US Department of Health and Human Services 2008 Persons in family Poverty Guidelines 1 $10, 400 2 14, 000 3 17, 600 4 22, 200 5 24, 800 6 28, 400 >7 Add $3, 600 for each additional person

Risk Factors for Women Young age Lack of recognition of partner’s risk factors High-risk heterosexual risk factors Biological vulnerability Substance abuse Socioeconomic issues

In 1985, women accounted for 8% of all people in the US living with AIDS. By 1992, it was up to 14%. By the end of 2005, this had grown to 23%. Women today now represent 27% of all people with HIV/AIDS. The Kaiser Family Foundation, 2008

“Minorities are disproportionately impacted by the AIDS epidemic. In fact, the sociodemographics of HIV/AIDS look strikingly similar to the sociodemographics of American prisons. ” Lachance-Mc. Cullough, Tesoriero, Sorin and Stern (1994)

Demographics of prisoners Per 100, 000 population 393: White 957: Latino 2, 531: Black Complete illiteracy 4% of all Americans 18% of prisoners Serving time in prison at some time 29% of African Americans 16% of Latinos 4% of Whites

Female Prisoners Young (2/3 under the age of 34) Minority (more than 60%) Unmarried (more than 80%) Undereducated (about 40% do not have a high school diploma) Underemployed Most convicted for nonviolent crimes

HIV/AIDS is: The leading cause of death for black women aged 25 -34 years The 3 rd leading cause of death for black women aged 35 -44 years The 4 th leading cause of death for black women aged 45 -54 years The 4 th leading cause of death for Hispanic women aged 35 -44 years

CDC recommends (2003) Making HIV testing a routine part of health care Implementing new models for diagnosing HIV infections outside medical settings Preventing new infections by working with HIV infected persons and their partners Decreasing perinatal transmission

Maternal Risks AIDS defining diseases more common in women include wasting syndrome, esophageal candidiasis and herpes simplex Vaginal candida and cervical pathology are prevalent among women at all stages of HIV infection

Clinical Thinking in Action Sally is a 17 year old woman whose last menses was 4 months ago when she had mono. At the time of her first prenatal visit, she had a pap, GC/Chlamydia, CBC, ABO and Rh typing, u/a, rubella titer and a hepatitis B screen done. She declined an HIV test since she felt that her boyfriend loved her, and would tell her if he was HIV+. Today, you are giving her the results of her tests, and her GC test is +. All of her other tests are negative or within the normal range.

Since Sally is 17 years old, do we need to consult her parents? Why or why not?

What would you include in your plan of care for Sally?

What are some things we have to consider while caring for a pregnant 17 year old teenager?

Critical Thinking in Action Sally is scheduled to return to the clinic for her HIV test results. The report has just come in, and her HIV test is +, and the Western blot test to confirm, is also +.

Does pregnancy accelerate the disease progression to AIDS?

What tests would we do for an HIV + woman who is considered high risk?

� HIV+ women are considered at increased risk for which complication? � Would you perform invasive procedures like amniocentesis or vaginal exams after their membranes have ruptured? Why or why not?

Asymptomatic Women—Pregnancy not believed to accelerate the progression of HIV/AIDS Women with low CD 4 counts---have accelerated progression of disease during pregnancy

Fetal-Neonatal Risks �½ of all infections occur during labor & delivery � For HIV+ women who receive no AZT during L & D, the transmission rate is 15 to 25% � With AZT, C-section and no breastfeeding, the transmission rate is 2%

Newborns Following birth, newborns will have + antibody tests, which doesn’t indicate infection Low birth weight (SGA) Premature

HIV and Breastfeeding causes 40% of all pediatric HIV infections John Hopkins study (April 2005) showed that exclusive breastfeeding substantially reduced the risk of HIV transmission through breastfeeding

Infants with AIDS Failure to thrive Hepatosplenomegaly Recurring infections Neurologic abnormalities/delayed developmental milestones Epstein-Barr virus

Clinical Therapy for the Pregnant Woman Voluntary HIV testing Care focused on stabilizing the disease, preventing opportunistic infections and the transmission of the virus to the fetus Antiretroviral therapy Evaluated and treated for other STI’s Pregnancy is considered high risk

Weekly nonstress tests starting at 32 weeks gestation Avoiding invasive procedures like amniocentesis and including vaginal exams after membranes have ruptured Women at increased risk for complications, ie hemorrhage, infection and poor wound healing

Hepatitis B A D C E

Hepatitis Inflammation of the liver Jaundice Anorexia Nausea/vomiting Fever

Hepatitis A & E Transmission: fecal-oral contaminated water Ø Not chronic Ø Immunization Ø Incubation available 15 -50 days

Hepatitis B & D Transmission: Blood & Body fluids Incubation: 45 -160 days Possibly chronic Immunization available

Hepatitis C Transmission: Blood & body fluids Incubation: 14 -180 days Chronic No immunization available

What are some risk factors for an STI? How do you prevent STI’s and their consequences?

References Center for Disease Control and Prevention. (2007). HIV/AIDS among women. [Fact sheet] Retrieved from http: //www. cdc. gov/hiv/topics/women/resources/factsheets/women. htm Chirwa, D. (2005, May). Africa and America, Black women face AIDS Crisis. The Crisis Online. Retrieved from http: //findarticles. com/p/articles/mi_qa 4081/is_200505/ai_n 15665748 Chisenga, M. , Kasonka, L. , Makasa, M. , Sinkala, M. , Chintu, C. , Kaseba, C. , Kasolo, F. , Tomkins, A. , Murray, S. , & Filteau, S. (2005). Factors affecting the duration of exclusive breastfeeding among HIV-infected women in Lusaka, Zambia. Journal of Human Lactation, 21, 266 -275. doi: 10. 1177/0890334405279251 Davidson, M. , London, M. , & Ladewig, P. (2008). Olds’ maternal newborn nursing & women’s health across the lifespan. (8 th ed). Upper Saddle River, New Jersey: Pearson Education, Inc. de. Paoli, M. , Manong, R. , Helsing, E. , & Klepp, K-I. (2001). Exclusive breastfeeding in the era of AIDS. Journal of Human Lactation, 17, 313 -320. doi: 10. 1177/089033440101700405 Enriquez, M. , Farnan, R. , Simpson, K. , Grantello, S. , & Miles, M. S. (2007). Pregnancy, poverty and HIV. Journal for Nurse Practitioners, 687 -692.

Kaiser Family Foundation. (2008, May). HIV/AIDS Policy Fact Sheet: Women and HIV/AIDS in the United States. Retrieved from http: //www. kff. org/hivaids/upload/6092_05. pdf Rojas-Guyler, L. , Ellis, N. , & Sanders, S. (2005). Acculturation, health protective sexual communication, and HIV/AIDS risk behavior among Hispanic women in a large midwestern city. Health Education and Behavior, 32, 767 -778. doi: 10. 1177/1090198105277330. Schroder, K. E. , Hobfoll, S. E. , Jackson, A. P. , & Lavin, J. P. (2001). Proximal and distal predictors of AIDS risk behaviors among inner-city African American and European American women. Journal of Health Psychology, 6, 169 -190. Shambley-Ebron, D. Z. , & Boyle, J. S. (2006). Self care and mothering in African American women with HIV/AIDS. Western Journal of Nursing Research, 28, 42 -59. doi: 10. 177/0193945905282317 Zaitzow, B. (2001). Whose problem is it anyway? Women prisoners and HIV/AIDS. International Journal of Offender Therapy and Comparative Criminology, 45, 673 -690. doi: 10. 1177/0306624 X 01456004

The nurse has presented a community education class on recommended health screenings for women. Which statement by a client indicates additional teaching is needed 1. Is a screening tool 2. Detects abnormal cells 3. Can be done every 5 years in some women, if all their previous paps are normal 4. Is recommended every year.

The 22 year old is scheduled for her first gyn exam. What can the nurse do to make the client more comfortable during the exam? 1. 2. 3. 4. Ask the client why she has delayed her first pap this long Tell her what she can expect during the exam Reduce her fear by talking to her about your philosophy of life Have her mother in the room

In teaching about HIV transmission, the nurse explains that the virus cannot be transmitted by: 10 1. 2. 3. 4. Shaking hands Sharing drug needles Sexual intercourse Breastfeeding

Which of the following contraceptive methods offers protection against sexually transmitted infections? 1. 2. 3. 4. Oral contraceptives Withdrawal Latex condom Intrauterine devices 10